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Men seek it out to combat low energy and decreased sex drive. Prescription testosterone has become so popular that so-called "low T" clinics are becoming common sights in cities and suburbs.

The number of testosterone prescriptions written in the U.S. more than tripled in the past decade. But researchers suspect that much of the testosterone dispensed at low-T clinics isn't tracked, since it's often bought with cash. This unfettered flow of testosterone — officially a controlled substance — has raised concerns among doctors who specialize in hormonal problems.

Hormone treatment itself isn't without risk: A recent study of more than 55,000 men found a doubling of heart-attack risk among older men who used testosterone. Younger men who had a history of heart disease had a higher incidence of nonfatal heart attacks. In addition, men who are on prolonged high-level testosterone replacement therapy can experience testicular shrinkage.

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If you’re a man and feel tired, moody and uninterested in sex, you could have an easy fix: testosterone replacement. That’s the message men have been receiving from TV commercials urging them to talk to their doctors about low testosterone or “low T” levels and touting the beneficial effects of prescription gels to manage symptoms associated with low hormone levels.

“What do men do when a number’s too low? Turn it up,” says a 50-something actor touting AndroGel, a popular testosterone treatment for men with low T.

But is it really that easy?

Physicians who treat low testosterone say the condition is far more complex than the commercials make it seem, and that men need to be carefully evaluated to determine whether the treatment’s potential benefits outweigh possible health risks that still haven’t been fully explored in research studies.

What’s more, some men who really could benefit from the therapy may have been scared off by recent news reports warning about heart attack risks associated with testosterone replacement.

Since testosterone levels tend to drop naturally as men age, a test to screen for low hormone levels should not be performed during a routine physical exam, according to the American Urological Association.

About 6 percent of men, however, have clinically low testosterone levels that cause troubling symptoms such as low sex drive, erectile dysfunction, sleep difficulties, depressed mood, low energy and low muscle tone. Some may develop osteoporosis or fractures from having too little of the sex hormone.

“Testosterone replacement therapy can help relieve symptoms in a lot of these men,” Morgentaler says. “It’s not perfect, but I don’t think men with symptoms should be scared off a therapy that’s working for them after reading news reports that it may cause heart attacks.”

Morgentaler and his colleagues recently conducted an extensive review of dozens of studies examining the risks and benefits of testosterone therapy and found only four that indicated an increased heart disease risk with the use of testosterone; two of the four studies had “serious methodological limitations” in terms of how they measured heart problems that developed in patients. Other studies found no increased heart risks, while others found that men with low testosterone levels had an increased risk of dying from heart disease if those levels went untreated compared to men who had testosterone treatment.

One of the more well-designed studies Morgentaler reviewed was a 2010 paper published in the New England Journal of Medicine which found that men over 65 with low testosterone levels who were treated with a daily testosterone gel for six months gained muscle strength and endurance compared to those who used a placebo gel – but testosterone users also had more heart attacks. Out of 209 study participants, 23 in the testosterone group had a heart attack or a blocked artery requiring treatment or died of heart problems during the study compared to five in the placebo group.

“There needs to be a bigger trial of cardiovascular risks with testosterone therapy to get the full answers,” Morgentaler says.

The National Institutes of Health is sponsoring a multicenter trial of nearly 800 men ages 65 and older with low testosterone to get a comprehensive understanding of how the treatment affects walking ability, energy levels, sexual function and plaque buildup on the arteries, for example. Results are expected later this year.

Men with low libido, erection difficulties and other symptoms of low testosterone need to get their blood levels tested to see if treatment is warranted. Getting an accurate read of levels can be tricky, so Brand Anawalt, chief of medicine at the University of Washington Medical Center and chair of the Endocrine Society’s Hormone Health Network, recommends having the blood test at least twice to account for day-to-day variations. A morning draw after fasting for six hours is best to get an accurate measurement, he says, since levels tend to be highest during morning hours and when fasting.

As a rule of thumb, the lowest level of total testosterone considered normal in men is 250 to 300 nanograms per deciliter. Men with symptoms who have a level of 150 ng/dL would likely benefit from treatment, Anawalt says, even if there’s no explainable cause for their low levels such as testicular cancer, testicular injury, hormonal disorders, or chronic liver or kidney disease. Those who have an explainable cause and a level of 250 ng/dL or below would also warrant treatment, he adds.

“The controversy starts to bubble when a man has a level of around 250 ng/dL without any clear reason to explain his low levels,” Anawalt says. “In general, I tell men that the benefits of treatment are much smaller when levels are closer to normal.”

Men who decide to get treated can choose between injections self-administered or given every one to two weeks, a skin patch or gels applied on the skin daily. The skin patch and gels are more expensive than shots costing about $180 to $300 a month, compared to $50 for generic shots. While shots are covered widely by insurance, Anawalt says, the patch and gels may not be. A new injection called Aveed only needs to be given every 10 weeks, but it costs the same as the gels, he adds, and many insurance companies aren’t yet covering it.

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